There Shall Be No Needy, Part 7: Society, Heal Thyself!

The importance of providing health care is such an assumption in the Jewish culture I grew up in that I was surprised to learn it was ever debated--but that just goes to show you how in Judaism, everything is open to debate! In chapter 7 of There Shall Be No Needy,  Rabbi Jill Jacobs gives respect to the minority view that it is up to God to heal sickness (not wounds), or that once upon a time in the age of prophecy that was the case. She rightly states that the overwhelming sentiment is that medicine is a mitzvah, for at least two reasons:

1. We were made in the image of God. Whoever heals a human being is doing a good thing on a cosmic scale!
2. Our bodies are our most valuable possessions. If it's a mitzvah to return my book, my coat, or my donkey that I have lost, what a greater good deed it is to return my health!

Ordinarily we don't pay someone for doing a mitzvah. As she has established in earlier chapters, however, rabbinic opinion is that Jewish communities can organize and regulate themselves for the sake of tikkun olam, which in this case means "to establish a health care system in which doctors and other potential lifesavers feel motivated to operate at their highest capacity, and in which patients can be expected to afford their treatments." But as she remarks:

These texts are especially troubling to read in contemporary American, where an inefficient and profit-driven health care system simultaneously makes it difficult for doctors to treat uninsured patients without risking their own livelihoods and prevents many patients from being able to afford needed medical care and medicine. (170-171)

As usual, Jacobs holds the U.S. to the standards she can find in the Jewish tradition and finds it wanting. Just to be clear, the Affordable Care Act passed the year after this book was published, yet I suspect it would not fundamentally alter her assessment: she is arguing that as Jews, we must demand much more from our society. In fact, she implies that any system that involves paying health insurance companies and having them make profit-driven decisions about health care is not acceptable by Jewish standards.

Star Trek Economics

 

Today, while shoveling, I heard Paul Ryan condemn Obamacare because it would give people more freedom to choose whether or not to work, and how many hours.

When I came in from shoveling, my sister Yael Fischman had shared this article with me about an economy where no one actually has to work.

I want to live in the Federation!

https://medium.com/editors-picks/29bab88d50

Who Cares? The Need for Personalized Communication

Today I received a letter in the mail from my health insurance company.  You are taking a certain medicine, they said, so every year, you should have a certain kind of blood test.  Are you doing that?  Will you ask you doctor to make sure?

The company called the letter a Care Alert, and everything in it reinforced the message, "We Care."  The envelope didn't: it looked as if it might have been one of those Explanations of Benefits that don't explain anything at all.  And of course, one of the reasons they care is that if I look out for myself, I can avoid serious health risks that would end up costing the insurance company a lot. 

Still, the message itself was caring.  It was personalized, and it treated me like a responsible adult who can make good decisions with the proper information.

I would like to propose that nonprofits aim at making all their communications as personal and as caring as the letter I received.

What would it take to do that?

1. Knowing, and remembering, a lot about your supporters. 
2. Thinking, "How can I make my agency useful to this person?"  What topics matter to him or her?  What information would she or he find useful--not in a general way, but here and now?  
3. Calling on them to take action...and showing them how.

The tools exist to make all this possible.  Databases, constituent relationship management software and processes, email tools, various programs that remind you it's time to send this kind of message to this specific person: they're out there, and not that expensive.

But is your organization willing to spend the time and attention it takes to treating every client, constituent, prospect, or donor with at least as much care as a health insurance company showed to me?

The Operation Succeeded but the Patient Died

Oops, they did it again.

The Boston Globe has once again written about the Massachusetts mandatory health insurance plan without ever asking the critical question: "Are people getting the health care they need?"

They ask whether people have insurance coverage. Sure, since they'd be scofflaws if they didn't! But being covered is not the same thing as getting care: not when you can buy insurance that doesn't kick in until after you pay a high deductible. That kind of insurance is a subsidy from the working poor to the health insurance industry: pay for something you can never use.

They ask whether it saves the state money. That's an important question, but only AFTER you answer "Are people getting the health care they need?" Because surely the state could save even more money by letting people die. Cost is not the primary issue, any more than coverage is. The primary issue is health.

They ask how small businesses react. That's a good question. Small businesses are justifiably concerned that they are subsidizing large health insurance companies, hospital chains, and the state. But it really shows the bias of the Globe that they ask about small businesses and not about the people who work in them.

They ask what effect this plan will have or should have on Romney's presidential campaign. Show me a mom working two jobs to support her family who's paying for health insurance and who still can't afford routine doctor's visits for her children who cares about that question. Find me one. Then I'll agree that the Globe cares even one little bit about the working people who need real health insurance--not the plan we've got.

Health Insurance Bill is a Ticking Bomb

I have been showing how the new federal bill that requires people to buy health insurance resembles the system we have here in Massachusetts, which is wrong and unfair. It forces people to buy coverage without actually getting care. It plays Robin Hood in reverse by sending working- and middle-class people's money to rich insurance companies and hospitals. It stigmatizes women who exercise their right to obtain an abortion. People who don't have health insurance yet think the Massachusetts plan doesn't give them what they need, and they resent having to pay for something that doesn't save them any money.

(It may be true, as my friend Larry Lennhoff says, that people will realize the value of health insurance the moment they have a catastrophic illness. For most of us, fortunately, that means never realizing it. It may also not be true. If the public was going to be on the hook for your care before, and now you are paying for insurance yourself, how does that make you happy?)

What I fear most about the new health insurance bill is that it may make people oppose ALL forms of publicly funded health care. Some people think this has happened already. They read the recent election of State Rep. Scott Brown to the U.S. Senate seat as a referendum on health care. I believe this is a whopping big mistake: the Democratic candidate, State Attorney General Martha Coakley, failed to mount any real campaign after she won the Democratic nomination. In effect, she gave the election away. Furthermore, I believe people took their frustrations with the corrupt Democratic monopoly of the Massachusetts legislature out in the Senate race. It doesn't matter that the two have nothing to do with each other.

Still, I do hear people complaining about the Massachusetts bill in casual conversation--in the public library, for instance, checking out books. People are forming the impression that if the government runs it, it's bound to favor the rich and hurt them. They have a lot of reason to think that, and the mandatory health insurance bill just adds one more. To me, that's the biggest reason to oppose it and want to replace it. When you're alienating voters who should be your strongest supporters, you need to think again--before it blows up in your face.

Stigma against Abortion: What's to Oppose in the New Health Care Bill. part IV

Abortion is a legal right. What's more, it gives women the opportunity to refuse to give their bodies to pregnancies they don't want, or spend years raising children they may not have the money or the will to raise. No man has to make that choice: the least we can do is support women in the choices they make. Yet the new mandatory health insurance bill passed by Democrats in Congress and signed into law by President Obama paints a scarlet letter on women who choose abortion.

Sharon Lerner wrote in The Nation:

When the debate moved to the Senate... another Democrat, Ben Nelson, led the charge to restrict abortion coverage, proposing an amendment requiring any woman who wants insurance to cover the procedure to write a separate check for that premium. The Nelson Amendment also requires health plans to keep funds for abortion separate.

Apparently, there is no problem with funding agencies that bomb civilians and torture prisoners, but health plans that pay for women to exercise their legal rights are so shameful the government of the people, by the people, and for the people cannot be seen to support them. This is a tremendous step backward for women's rights and health, as well as for equality in America.

Uninsured Don't Think the Answer is Forcing Them to Buy

I've been recapping the Massachusetts experience with mandatory health insurance, asking what it can tell us about the federal plan just passed. Back in 2008, I wrote:

If you believe the papers, the politicians, or the pundits, the Massachusetts plan to make sure everyone has health insurance--by forcing them to buy it for themselves--is a great success. The uninsured don't believe it, however. Neither do low-income people in Somerville, where I live. Neither do I.

According to the Boston Globe, "The number of uninsured adults in Massachusetts fell by almost half last year." Proponents of mandatory health insurance said "that not only are more people getting coverage, but that only a fraction of taxpayers contested the health insurance mandate."

Sounds like great news, right? It does--until you look at who supports mandatory health insurance and who doesn't. People who already have insurance favor the plan by 71%. Not surprising: it doesn't cost them anything out of pocket, and the taxes needed to fund the plan haven't kicked in yet. But a majority of people who don't have health insurance yet--the people the plan is theoretically supposed to benefit--don't support it, according to a study by the Massachusetts Dept. of Revenue.

In Somerville, where I live, we recently [in 2008] surveyed 537 mostly low-income residents or employees. We asked them what should be the top priority of CAAS, the anti-poverty agency where I work. Keeping housing safe and affordable was the $1 priority (not a surprise, given the high cost of housing in our area). English literacy and finding a job, or a better job, were essentially tied at #2. "Access to health insurance" ranked #3. The people who need health insurance the most are telling us that the Massachusetts plan is still a problem and not yet a solution.

You MUST Buy Health Insurance--Corporations Need Your Money!

I've been sharing the Massachusetts experience with mandatory health insurance with my readers, so you can know what to expect from the federal plan that's modeled on Massachusetts. Expect Robin Hood in reverse: a big subsidy by the working poor and middle to the richest of the health care providers. I originally published this piece last summer.

Massachusetts requires all residents to buy health insurance, even if it means coverage without care. Buying a health plan with a high deductible means paying for nothing, which is what thousands of Massachusetts residents are doing. But it's worse than that.

It turns out that our state government forced struggling young people and families into the insurance business partly so that hospitals didn't have to give them free care any more. "Today, hospitals typically spend about 1 percent of expenses on free medical care, as measured by the attorney general, half of what they spent before reform made insurance available to many more low-income people," according to the Boston Globe.

Meanwhile, nonprofit hospitals are making a profit out of their tax-exempt status--an exemption granted to them largely so that they could offer free care!

The 10 leading hospital companies benefited from an estimated $638 million in federal, state, and local tax breaks as well as state discounts on borrowing in 2007, the latest year for which complete data are available. More than half of that goes to two large and growing companies, Partners and Children's Hospital. Overall, the 10 hospital companies' tax breaks and other benefits were worth $264 million more than the value of the "community benefits" - care for the poor and other charity work - they reported to the state attorney general that year.

It's important to mention the hospitals that ARE offering a lot of free care: "Three companies - Tufts Medical Center, UMass Memorial Health Care (owner of UMass Memorial Medical Center in Worcester) and Boston Medical Center - reported spending more on community benefits than the value of their tax breaks as estimated by the Globe." But they are the shining exceptions--and Boston Medical Center is having severe financial troubles because of its commitment to serving the poor.

In short, so-called nonprofits like MGH and Children's Hospital are stiffing the poor, and we are giving them a tax break at the same time. This should be the shame of Massachusetts.

Coverage Without Care: What's to Oppose in the New Health Care Bill. part I

OK, so last week, in all fairness, I pointed out that the health insurance bill does contain some provisions that will help people--especially really poor people or really young adults (26 and under). In general, however, the national health insurance plan follows the path already trod in Massachusetts. Having lived under it, the Massachusetts plan is not one I would recommend.

What's wrong with it? Plenty. Let's start with one issue I have been observing for almost a year now: coverage without care.

I wrote on May 4, 2009, "Across Massachusetts, people are facing a stark choice: pain or poverty. The mandatory health insurance law forces people to buy some kind of coverage, but often, what people can afford won't pay for the care they need. In today's Boston Globe, Judi Campbell of Northampton says she's putting off hip surgery because she already owes the hospital $1,000 for arthritis-related surgeries her insurance wouldn't cover."

"And yet the Globe and many policy makers proclaim the "success" of the Massachusetts health insurance plan. For shame!"

On June 21, I wrote:

"The Globe reports:

People with robust [sic] health insurance are putting off doctors’ appointments and skimping on prescriptions because they can’t afford the increasing costs of copayments and deductibles, according to managers of patient-assistance hot lines in Massachusetts.

"All right, let's give the reporters credit. Never mind the logical impossibility of health insurance plan being "robust" if you can't actually use it. (The operation was successful, but the patient went broke?) Also, forget about the fact that this only becomes news when it affects middle-class people, the kind who thought they were already well insured. "

"Let's be happy that finally, it's front-page news that the Massachusetts individual mandate to buy health insurance is failing to deliver actual health care to a large and growing number of people. The key word here is "failing." This is not a model for national health insurance. It's an object lesson in what happens when the hospitals, insurance companies, and doctors all design a health plan without the slightest thought for its effects on actual patients."

Next installment: how the Massachusetts health insurance plan is Robin Hood in reverse--and the federal government follows suit.

What's to Like about the New Health Insurance Bill

How should we regard the new health insurance bill that President Obama just signed into law? On Monday, I gave an overview. For the next few days, let's go into the details.

Compared with the system we have now, there's plenty to like about the new plan. Based on a summary in the Boston Globe, here are some of the good points:

More money for states to pay for poor people's health insurance. "Massachusetts would receive a $2 billion boost in Medicaid assistance over 10 years to help pay for insurance coverage for low-income residents." Medicaid plans let poor people get decent health care they couldn't afford otherwise.

More money to help moderate-income people pay for their own health insurance. "Tax credits are provided to help pay for insurance, and that aid is available for people with incomes up to four times the federal poverty level, which is $88,2oo for a family of four and $43,32o for an individual."

Fewer denials of coverage. "The measure would prohibit insurance companies from denying coverage because of a preexisting condition," within six months for children and by 2014 for adults. It also lets young adults stay on their parents' plans until they turn 26 (meaning fewer will go without health insurance), and it makes sure Medicare pays for elders' prescription drugs (eliminating the "doughnut hole" in which, if you paid more than $2,700 a year for prescriptions, you were on your own until your expenses mounted to $6,200). People with pre-existing health problems, young people, and seniors make up a large part of the population! They will all be better off because of these provisions.

Coverage for legal immigrants. Currently, the federal government provides no help at all to legal immigrants seeking health insurance. In 2014, under the new bill, the feds would send money to state governments like Massachusetts which choose to subsidize health insurance for low- and moderate- income legal immigrants the same way as they subsidize low- and moderate-income American citizens.

If your question is, "Will anybody be better off under the new bill than they were before?", then the answer is, "Yes, lots of people will." And I agree with columnist Scot Lehigh that Obama and the Democrats need to go on tour to promote it. They should use every mass marketing and social networking trick in the book to spread the word and build support for the bill.

That doesn't mean I think it's a good bill. Why? Come back tomorrow to find out.

The Blessing and the Curse of the Health Insurance Bill

Democrats will say that the health insurance bill which passed the House of Representatives last night is a historic expansion of the right to health care. Republicans will say that it's full of loopholes and sweetheart deals and that it costs too much.

They're both right.

We in Massachusetts have lived under something a lot like the new federal health insurance system. We are in a privileged position to tell the rest of the nation what to expect. Over the coming days and weeks, I will try to do just that.

Here's a hint at what you're likely to hear from me. I work in an anti-poverty agency, and the way that both the Massachusetts and the federal bill expand high-quality care to the poorest of the poor is something I can applaud. Plus, everyone can be happy that insurance companies will have to cover people regardless of pre-existing conditions--and that they have to cease and desist dropping people's coverage once they get sick. These are real gains.

For people who are not among the poorest, this bill is bait and switch. It promises health care, but only delivers on health insurance, mostly at our own expense. The kinds of health insurance that many working poor and even middle-income people will be forced to buy won't help them with the things they need most: doctor visits, preventive care, prescription drugs. Instead, they'll be required to send their hard-earned money to fatten insurance company profits for policies that only kick in when they have medical emergencies. By delivering new customers to already-wealthy insurance companies while not paying attention to the daily needs of the working and middle classes, Obama and the Democrats are creating a constituency that will blame them, think of them as out of touch, and be open to manipulators like Scott Brown.

The country would be better off if our rulers had passed the Medicare-for-all type system that most people want. It would include everybody, meet all their basic needs, and cost much less. But it was never seriously discussed. That's why we're left picking out crumbs of good news on a day when we should have been able to feast on victory.

Election Distraction

Should we end the war in Afghanistan as quick as we can, or possibly send in more troops? Can we provide health care (not just insurance!) to everyone who needs it, and will that mean putting private health insurers out of business? Is the recession slowing down, and for whom: is it good news if unemployment is still in double digits in certain regions? How do we stop nuclear proliferation, and global warming? Is it really a sign of progress when a woman in Iran stands up for the right to wear pants without being flogged for it, but women in many parts of the U.S. have to travel for hours to get the reproductive services (including both contraception and abortion) that the Constitution protects? How can the states pay for vital services and schools without going bankrupt?

All these questions, and many more, are serious and should be at the top of the agenda. But in Massachusetts, we're arguing about whether the governor should be able to appoint an interim U.S. Senator to take Ted Kennedy's seat or whether we have to wait five months to elect somebody. Huh?

OK, I know these questions are related. I have a Ph.D. in political science: no need to rehearse the arguments with me. The point is that whether it's an appointment, an election, or a coronation, it's also a distraction. Whoever we elect will only do as good a job as we force him or her to do. We should be focusing on the issues, not the candidates.

Further Away from Universal Health Insurance in Massachusetts

"We don't really care whether everybody gets insurance."

The Massachusetts Health Connector might as well emblazon that message on a banner and hang it the middle of Boston Common. It's what they're saying anyway by cutting the plan back 12%.

Already, as I have noted, many people in Massachusetts had coverage without care, because they couldn't afford to pay for the plan AND the deductible. Instead of paying the doctors, they paid the health insurers for plans that didn't give them anything.

Tuesday, the board of the Commonwealth Health Connector, which runs the mandatory insurance plan, dropped the last vestige of a pretense that everyone would even get insurance (useable or not). Are you a low-income resident, entitled by law to a full subsidy, but you forgot to sign up? Too late now. You and 18,000 people like you are out of luck. Even if you did what you were supposed to and enrolled, the Connector just snapped its collective fingers and took away your dental care. Or were you born in Ireland, or Greece, or Haiti, or El Salvador, and came to this country with full legal status? Tough. The feds aren't going to pay their share to insure you, so Massachusetts has decided you're just too expensive.

What makes it worse is that groups like Health Care for All, who should be marching in the streets, are busy making excuses for Massachusetts instead.

But the group said state officials appear to have made the best of a bad situation. “There’s no other place to go for money,’’ said Lindsey Tucker, the organization’s healthcare reform manager. “. . . My concern is people will not get the care that they need.’

Damn straight they won't! And it is not a health advocate's place to take the state off the hook. There are plenty of places to go for money. We just need politicians with backbones, and voters with consciences. We won't get either by dumping low-income and immigrant residents over the side of the leaky health insurance plan to lighten the load for the rich and powerful in this state.

Finally, They Ask Who's GETTING Health Care

The Globe reports:

People with robust [sic] health insurance are putting off doctors’ appointments and skimping on prescriptions because they can’t afford the increasing costs of copayments and deductibles, according to managers of patient-assistance hot lines in Massachusetts.

All right, let's give the reporters credit. Never mind the logical impossibility of health insurance plan being "robust" if you can't actually use it. (The operation was successful, but the patient went broke?) Also, forget about the fact that this only becomes news when it affects middle-class people, the kind who thought they were already well insured.

Let's be happy that finally, it's front-page news that the Massachusetts individual mandate to buy health insurance is failing to deliver actual health care to a large and growing number of people. The key word here is "failing." This is not a model for national health insurance. It's an object lesson in what happens when the hospitals, insurance companies, and doctors all design a health plan without the slightest thought for its effects on actual patients.

Feeling Ill about Health Care Debate

Following the health care debate is enough to make you sick.

Here in Massachusetts, supporters of the state's mandatory health insurance plan talk about how many people now have insurance and how much money that's going to save the hospitals and the state treasury. Critics mostly talk about the cost of the plan and how, soon, paying for those who can't pay for themselves will drive the state to the poorhouse. Some point out that businesses are providing their employees with health insurance plans that don't meet the minimum standards set out in state law, and daring the state to catch them.

All this is beside the point. The goal should not be to provide people with health insurance but to ensure their right to health care. Plans that cost low- to middle-income households a lot of money up front--plans with a high deductible, to use the industry's bland euphemism--insure coverage without care. And that leaves people just as sick as they were before, just a little poorer.

At the federal level, besides using Massachusetts as a model (!), Obama is doing the usual liberal dance: offering something that makes him feel good but doesn't do the job.

• "President Obama will sign a presidential memorandum today to extend benefits to same-sex partners of federal employees, administration officials said last night, but he will stop short of pledging full health insurance benefits," reports the Boston Globe.
• "A key Senate committee voted yesterday to expand a children's health insurance program to cover an additional 4 million uninsured children," but that still leaves many uninsured, and it says nothing about what happens to children when their parents fall ill.
• The current debate is over whether the federal plan should include a "public option." Proponents say that a public plan would give people more choices--which is only meaningful if the choices are any good, and if they differ in significant ways. They also say competition from a public plan would force private insurers to find ways to cut costs. Critics say the public plan could get a public subsidy and put private insurers out of business.

"In response, Senator Charles Schumer, Democrat of New York, has proposed setting ground rules for a public plan that would force it to compete on a level playing field with private insurers." In other words, get rid of the main reason for having a public plan in the first place, its ability to serve huge numbers of people at low cost!

Schumer is no different from the leader of his party in this respect. President Obama has done all but take a blood oath that his plan is not a "Trojan horse" leading the way for a single-payer system. That's exactly what's wrong with it! Single-payer means everybody gets health insurance as a right, the same as the right to vote or the right to a public education. The fact that the Democrats are falling all over themselves to rule out a single-payer solution is what's so sickening about what passes for a health care debate.

You Must Buy Health Insurance--MGH Needs Your Money

I will get back to the delights of midrash in a bit--but first, the latest outrage from the Massachusetts health care system.

Massachusetts requires all residents to buy health insurance, even if it means coverage without care. Buying a health plan with a high deductible means paying for nothing, which is what thousands of Masschusetts residents are doing. But it's worse than that.

It turns out that our state government forced struggling young people and families into the insurance business partly so that hospitals didn't have to give them free care any more. "Today, hospitals typically spend about 1 percent of expenses on free medical care, as measured by the attorney general, half of what they spent before reform made insurance available to many more low-income people," according to Sunday's Boston Globe.

Meanwhile, nonprofit hospitals are making a profit out of their tax-exempt status--an exemption granted to them largely so that they could offer free care!

The 10 leading hospital companies benefited from an estimated $638 million in federal, state, and local tax breaks as well as state discounts on borrowing in 2007, the latest year for which complete data are available. More than half of that goes to two large and growing companies, Partners and Children's Hospital. Overall, the 10 hospital companies' tax breaks and other benefits were worth $264 million more than the value of the "community benefits" - care for the poor and other charity work - they reported to the state attorney general that year.

It's important to mention the hospitals that ARE offering a lot of free care: "Three companies - Tufts Medical Center, UMass Memorial Health Care (owner of UMass Memorial Medical Center in Worcester) and Boston Medical Center - reported spending more on community benefits than the value of their tax breaks as estimated by the Globe." But they are the shining exceptions--and Boston Medical Center is having severe financial troubles because of its commitment to serving the poor.

In short, so-called nonprofits like MGH and Children's Hospital are stiffing the poor, and we are giving them a tax break at the same time. This should be the shame of Massachusetts.

The Boneyard

Annals of military spending:

Some stylish people--fewer, since the recession stated--trade in their used cars every year or two for the very latest model. The U.S. Air Force engages in even more conspicuous consumption. The third largest air force in the world is sitting on the ground in Tucson, Arizona. More than 4,400 aircraft and 13 aerospace vehicles sit idle at the 309th Aerospace Maintenance and Regeneration Center (AMARG), also known as the "Boneyard."

The Boneyard is not only a resting place for planes. I look at each of these airborne behemoths and I realize that it is an unwitting memorial to lives we could have saved.

This country had the choice to fund the war on poverty--to end cancer, or AIDS--to make sure every adult and child had top-quality health care from before birth to the final rest. Instead, we spent billions of dollars producing the aircraft that have ended up baking in the Arizona sun, just another tourist attraction.

Insuring pain--or poverty

Across Massachusetts, people are facing a stark choice: pain or poverty. The mandatory health insurance law forces people to buy some kind of coverage, but often, what people can afford won't pay for the care they need. In today's Boston Globe, Judi Campbell of Northampton says she's putting off hip surgery because she already owes the hospital $1,000 for arthritis-related surgeries her insurance wouldn't cover.

And yet the Globe and many policy makers proclaim the "success" of the Massachusetts health insurance plan. For shame!

If This Were Reform, It Would Have Different Friends

I've written before that the main problem with the Massachusetts mandatory health insurance plan is that it mandates coverage--but not care. Are we about to see that problem made larger on the national level?

"Lobbies backing health reforms," today's Boston Globe headline screams. "Insurers change their tune from 1993-94 debate." But the article makes it clear that insurance companies are getting involved only so they can protect their own interests, not those of the patients who need the care. It quotes Karen Ignagni, the president of "the nation's largest health insurance lobbying group":

"Strategically, industries have choices if they're at the epicenter of the discussion about a certain part of the economy," she said. "They can sit and wait for others to develop proposals or take the bull by the horns and look at what are the issues that are troubling the country, what are the issues that need to be resolved to help improve the productivity of the country. . . . It's not an altruistic strategy, it's a realistic leadership strategy."

And the insurance companies certainly do have a dog in this fight.

The insurance industry, meanwhile, could gain or lose depending on which reforms are adopted: Offering tax credits or subsidies to help pay for private coverage for the uninsured could bring insurers millions of new customers; but if a reform law also lets people choose a public Medicare-style plan, private insurers could lose business.

As they should! Here is an early warning signal that the Obama administration may become the third term of the Clinton era. To stop this backsliding in its tracks, check out Health Care for America Now. For the solution we really need, see your doctor: Physicians for a National Health Program.

Where We Need to Change Obama

I don't agree with his accusatory tone--I think most people voted for Obama with their eyes open--but Sam Smith has "listed nearly three dozen things that Obama supports or
opposes with which no good liberal or progressive would agree." Most prominent among them to my perspective:

• Ending the occupation of Iraq only to send more troops into Afghanistan.
• Trying to provide health insurance to people by mandating they buy it, instead of providing health care to people and cutting out the insurance industry completely.
• Recognizing loving relationships between men and men or women and women through civil unions, and denying them the equal rights that the word marriage confers.
• Double the funding for charter schools instead of working to make public schools into places of education for all.

On each of these points, we will have to use the movement tactics that Obama has mastered to bring pressure against him.